Population Health Management Interventions

Using a paramedic Care Coordinator working in conjunction with the ED physician to reroute non-emergency patients to established outpatient care protocols. EDS works to decrease the volume of avoidable or borderline admissions from the ED by providing outpatient resources to beneficiaries/patients. These services are provided by an onsite resource: the EDS Care Coordinator. The Care Coordinator works in conjunction with the ED physician to identify patients who do not require admission, but do need additional resources or care. Some of these additional resources include scheduled home visits within two days; consultation in the ED with a community paramedic, who evaluates the patient’s health, can offer transportation home, a home evaluation and then a follow-up visit at the patient’s home the next day. At all times, those working within the EDS program schedule an appointment for the patient with their PCP.

Full-service care centers for Medicare patients with chronic acute conditions. The CCC offers support for transition of care, and also as a facility to receive primary care from an HFACO provider. Currently, HFHS has two CCCs – Taylor and Detroit Northwest. The CCC is a practical care option for beneficiaries with chronic, acute health conditions and need more support from the clinical staff. The goal is improved health of patients while reducing inpatient admissions and ED visits. New to the CCC in 2018 is the use of Community Paramedics. Paramedics can schedule up to three visits with a CCC patient to ensure continuity of care, monitoring of health and the patient's ability to comply with health recommendations.

Connecting the case management pathways between inpatient and outpatient worlds, this team closes the gaps in care and streamlines case management to benefit the patient. The ICM team has adjusted its work model to create more value for patients through improved communication, streamlined workflow, and centralized leadership. These changes, in part the result of best practice recommendations from Deloitte and West Monroe Consulting firms, heightens the integration of case management to provide safer care transitions better coordination among all teams involved in the patient’s care, higher patient satisfaction and improved patient outcomes.

Agreements with selected, external hospitalist groups at non-HFHS hospitals where HFPN-contract patients are commonly admitted. These hospitalist groups agree to coordinate the care of patients who are admitted to their hospital in exchange for the exclusive right to manage patients covered by HFPN contracts at their facility. These hospitalists then reconnect patients with their HFPN PCP or a specialist, if needed, upon discharge.

PAC-S focuses on the appropriate flow of care from the hospital (inpatient, observation or ED) and a Skilled Nursing Facility (SNF), and also between a SNF and home. The PAC-S team focuses on gaps in care and communication that result when a patient is admitted to a Skilled Nursing Facility (SNF). The PAC-S program creates more contact points with the patient and their progress so that they are not kept in a care facility beyond when it is helpful or appropriate for them. The goal is to get the patient home as safely and as soon as possible. As part of this, the HFPN has created a SNF Preferred roster, which identifies a network of SNFs that are affiliated with Henry Ford hospitals and value-based care populations.